CQC report explained · a residential care home
What the CQC found at 21 Potterill Lane
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, staffing levels were safe, recruitment checks were followed and medicines were given and recorded correctly.
- Effective?
- Good
- People's needs and choices were assessed, and staff had suitable training and supervision. People were supported with meals, healthcare, mobility and their diagnosed conditions.
- Caring?
- Good
- Staff were described as caring and compassionate. People were treated with dignity, involved in decisions and supported to build independence and maintain relationships.
- Responsive?
- Good
- Care plans were personalised and reviewed when needs changed. Communication needs, activities, community links, complaints and end of life wishes were supported.
- Well-led?
- Good
- Inspectors found a positive, person-centred culture. The manager and staff understood their roles, used quality checks and worked with families, professionals and community organisations.
What inspectors found, June 2019
Avocet Trust - 21 Potterill Lane was rated Good; inspectors found safe, kind and personalised care with strong support for independence.
This was a planned inspection. One inspector visited on 8 May 2019 and reviewed the home, care records, medicines, staffing and safety documents. They spoke with two people, the registered manager and three staff. Recruitment and training records were checked at the provider's headquarters on 10 May 2019.
The home was supporting three people with learning disabilities or autistic spectrum disorder, and could support up to four. Inspectors found people were safe, their medicines were managed properly and staffing levels were suitable. Staff had the training and support needed to meet people's health, communication and daily living needs.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home was also rated Good overall. This was the same overall rating as the previous inspection, published in December 2016.
Safe medicines and staffing
Medicines were managed by trained staff and staffing levels were considered sufficient for people's needs.
“Medicines were safely managed by trained staff and people received them as prescribed, which assisted them to maintain good health.” from the report
Choice and independence
People were supported to make choices, learn skills, use local services and take part in everyday activities.
“People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.” from the report
Caring relationships
Inspectors saw that people trusted staff and responded positively to their support. Staff took time to understand people's preferences.
“Staff were caring. People trusted staff as they sought staff company and responded well to their interactions with them.” from the report
Personalised communication
The home used different ways to help people understand information and express their wishes, including signs, pictures and written information.
“Strategies were used to enable people to receive information in a format they understood.” from the report
Positive leadership
The manager and staff created a friendly and person-centred culture, with regular checks and meetings to review quality.
“The registered manager and staff promoted a friendly, homely, caring and positive culture where people experienced good outcomes and were supported in a person-centred way.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you involve my relative and our family in creating and reviewing their personalised care plan?
- 02How will you support my relative to make choices, learn skills and become more independent?
- 03How will you communicate with my relative and make sure information is provided in a format they understand?
- 04How do you check that medicines are given correctly and that records remain accurate?
- 05How will you support my relative to take part in activities, maintain relationships and use local community services?
This was a planned comprehensive inspection covering all five CQC questions, the premises and the care provided; the previous overall rating was Good. This explanation was written from the published report of 27 June 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2016
Rated Good overall; inspectors found kind, person-centred care, but safety systems needed improvement.
Inspectors made an unannounced visit on 28 November 2016. They observed care, spoke with staff, a person living at the home and relatives, and checked care, medicines, staff and management records.
The home was rated Good overall. Inspectors found caring staff, person-centred support, enough staff, safe recruitment, appropriate medicines support, and good help with health, food, activities and family relationships.
The Safe rating was Requires Improvement. Money belonging to people was kept in an unlocked safe, some food and temperature records were incomplete, and disposable gloves were not stored securely. Inspectors said the quality checks had not found these problems.
The other four areas were rated Good: Effective, Caring, Responsive and Well-led. The previous inspection in April 2015 found the provider compliant in all areas assessed.
Kind and respectful care
Inspectors saw positive relationships between staff and people. Staff respected privacy, dignity, consent and people's choices about when to spend time alone.
“Interactions between staff and people who used the service were seen to be kind and caring.” from the report
Person-centred support
Care plans described people's likes, dislikes, routines and communication needs. Staff understood how each person preferred to receive support.
“We looked at the care plans for two people who used the service and found these to be well organised, easy to follow and person centred.” from the report
Staffing and training
There were enough staff for the people's current needs. Recruitment checks, training, supervision and appraisal were in place.
“We found there was sufficient staff on duty to meet the current needs of people who used the service.” from the report
Activities and family contact
People were supported to take part in activities they liked, go into the community and maintain relationships with relatives and friends.
“Records of all activities people had engaged in were recorded.” from the report
Medicines and healthcare
Medicines were administered as prescribed and checked. People were supported to attend health appointments and receive professional advice when needed.
“Medicines were administered as prescribed.” from the report
Money was not stored securely
seriousSafety deposit tins containing people's money were kept in an unlocked safe. Inspectors said this could create an opportunity for financial abuse.
“Not all staff recognised how their actions in not following organisational procedures, had the potential to provide an opportunity for financial abuse.” from the report
Important records were incomplete
needs fixingSome fridge, freezer and food temperature records had gaps. This meant the home could not show that food was always prepared at the correct temperature.
“We saw improvements needed to be made to ensure records were fully completed in relation to food temperatures and fridge and freezer temperatures as we found some gaps in recording.” from the report
Some safety arrangements needed clarification
needs fixingOne person's evacuation plan referred to two staff but did not explain what should happen at night when only one staff member was on duty.
“We saw that improvements were required to one person's personal evacuation plan, it referred to two staff being available within the service and did not guide staff what to do for example during the night when only one staff member was on duty.” from the report
Gloves were not stored securely
minorA box of disposable gloves was left in a bathroom. Staff removed it during the inspection, and the manager said a lockable cupboard would be requested.
“However, during a tour of the building we found a box of disposable gloves had been left in a bathroom and had the potential to present risks.” from the report
Quality checks missed problems
needs fixingThe home's monitoring system had not identified the shortfalls in money storage and record keeping before the inspection.
“The quality monitoring system had not been effective in identifying these shortfalls.” from the report
- 01Where are residents' money and safety deposit tins stored now, and who checks this?
- 02How do you make sure fridge, freezer and food temperature records are completed every time?
- 03Has the personal evacuation plan been rewritten to explain what happens when only one staff member is on duty at night?
- 04Where are disposable gloves now stored, and how is this checked?
- 05What changes have been made to the quality monitoring system since this inspection?
This was an unannounced inspection covering all five key questions, with observations, discussions and checks of care, medicines, staffing and management records. This explanation was written from the published report of 21 December 2016 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of 21 Potterill Lane
3 rated inspections over 4 years: the service has held its Good rating throughout.
- June 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 1 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £1,020 to £1,350 a week. 12 can care for a couple. 8 years' experience on average.
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